Dr White
Flanagan
Models : there's a lot of variability in the models. Variability of patients, or parameters (ex halflife of lorazepam can vary from 22mn to 40mn).
80% of stomach content lorazepam was metabolite, 20% free lorazeapm (??? Flanagan language, I'm not sure I got that right)
Showing the lorazepam model that includes 16mg oral consumption (the model is based on 0.0013 mg in the stomach content) If you move the oral intake to 8o'clock , the amount of free lorazepam would be 0.008 mg in the stomach content, and concentration level would be close to concentration found at autopsy . There's anumber of scnarios that would lead to the results found at autopsy. We don't know how many pills he took, at what time.
About the 0.3 free propofol in urine content : showing a model about the 100 ml propofol infusion over 3 hours , with a model of free propofol in the urine . The level of propofol is around 2mg , the range would be from 1mg to 3 mg of free propofol in the urine. 1mg is 10 times the amount found at autopsy.
The burn feeling of propofol is increased by small veins, the concentration of the drug, the speed of the injection. Lidocaine would be given before the infusion, or at the beginning. Given the halflife of lidocaine , with a 3 hours infusion, there shouldn't be lidocaine found at autopsy, and there was 0.84 mg/ml at autopsy.
If there were 2 injections, lidocaine would have been given twice, Dr White would expect the lidocaine to be around the level found at autopsy.
Standard of care vs Standard of practice : standard of care is the ideal we would seek for every patient. It's not always possible. Ex capnography , it's useful , but not precise enough, and in many situations it's not used.
Anxiolisis : reduction or prevention of anxiety. To relieve anxiety you give axiolitics, example : benzodiazepine, propofol, ambien. There's degrees of sedation, depending on the dose, of the patient, if a patient has been exposed to the drugs before.
Minimal sedation: normal response to verbal simulation.Example given by Flanagan : If I took an ambien, would you be able to wake me up by talking to me.
25 mg propofol given over 3 to 5 mn : would produce reduction of anxiety, generally do not produce sleep. It's possible that if the person is very tired, it could produce a «*restful state*». Noise in the room would wake the patient up.
Dr Richelle Cooper said she was not sure that with 25 mg the patient would sleep , do you agree with that ? Yes
Minimal sedation : airway is not affected, breathing is not affected, no effect on cardiovascular function.
Break